Lung and Intercostal Upper Abdomen Ultrasonography for Staging Patients with Ovarian Cancer: A Method Description and Feasibility Study.

A detailed transabdominal and transvaginal ultrasound examination, performed by an expert examiner, could render a similar diagnostic performance to computed tomography for assessing pelvic/abdominal tumor spread disease in women with epithelial ovarian cancer (EOC). This study aimed to describe and assess the feasibility of lung and intercostal upper abdomen ultrasonography as pretreatment imaging of EOC metastases of supradiaphragmatic and subdiaphragmatic areas. A preoperative ultrasound examination of consecutive patients suspected of having EOC was prospectively performed using transvaginal, transabdominal, and intercostal lung and upper abdomen ultrasonography. A surgical-pathological examination was the reference standard to ultrasonography. Among 77 patients with histologically proven EOC, supradiaphragmatic disease was detected in 13 cases: pleural effusions on the right (n = 12) and left (n = 8) sides, nodular lesions on diaphragmatic pleura (n = 9), focal lesion in lung parenchyma (n = 1), and enlarged cardiophrenic lymph nodes (n = 1). Performance (described with area under the curve) of combined transabdominal and intercostal upper abdomen ultrasonography for subdiaphragmatic areas (n = 77) included the right and left diaphragm peritoneum (0.754 and 0.575 respectively), spleen hilum (0.924), hepatic hilum (0.701), and liver and spleen parenchyma (0.993 and 1.0 respectively). It was not possible to evaluate the performance of lung ultrasonography for supradiaphragmatic disease because only some patients had this region surgically explored. Preoperative lung and intercostal upper abdomen ultrasonography performed in patients with EOC can add valuable information for supradiaphragmatic and subdiaphragmatic regions. A reliable reference standard to test method performance is an area of future research. A multidisciplinary approach to ovarian cancer utilizing lung ultrasonography may assist in clinical decision-making.

Primary ovarian clear cell carcinoma of the abdominal wall--a systematic review of the literature to establish optimal surgical management.

UNLABELLED: Primary ovarian clear cell carcinoma of the abdominal wall (AW-OCCC) is an extremely rare occurrence. Therefore, data on the prognosis and treatment regime remain limited. OBJECTIVES: The aim of the study was to provide an evidence-based review of the available case reports to establish optimal surgical management. MATERIAL AND METHODS: A literature search according to PRISMA guidelines was performed using PubMed database (from 01.01.1990 to 31.12.2013) with the terms: "clear cell carcinoma" and "abdominal wall". A total of 17 case reports on 18 patients with full text available were identified. RESULTS: All AW-OCCC's appeared after previous laparotomy for gynecological reasons, with cesarean section as the predominant intervention (15/18, 83%). Median age was 46 years (range 37-56) and median time elapsed between the initial laparotomy and the cancer was 19 years (range 9-30). Data on the course of the disease were available for 17 cases. The overall median follow-up was 11 months (range 1-60). No cases of metastatic spread to the ovaries or the intraperitoneal cavity were observed. Eight patients experienced recurrence (8/17, 47.1%). Metastatic lymph nodes appeared in 6 of the 8 relapsed women and local recurrence in the remaining 2 subjects. There were 4 fatal cases (4/17, 23.5%), including 3 with lymphatic cancer spread. The women with treatment failure (recurrence or death) more frequently developed lymph node metastases than the curable cases (p=0.002). CONCLUSIONS: Radical resection of the tumor with concomitant pelvic lymph nodes dissection seems to be the most suitable surgical approach. The need for comprehensive intraperitoneal surgical staging for ovarian cancer is questionable.

Usefulness of diagnostic indices comprising clinical, sonographic, and biomarker data for discriminating benign from malignant ovarian masses.

The objective of this study was to review the accuracy of indices combining several diagnostic variables, in comparison to other models, sonography alone, and biomarker assays, for predicting benign or malignant ovarian lesions. Different single modalities were reviewed. The most useful complex models were International Ovarian Tumor Analysis (IOTA) sonographic logistic regression model 2 (area under the curve, 0.949), risk of malignancy index-cancer antigen 125-human epididymis protein 4 (0.950), risk of malignancy algorithm (0.953), pelvic mass score (0.960), non-IOTA logistic regression model (0.970), and histoscanning score logistic regression model (0.970). None of the indices was superior to an expert subjective sonographic assessment (0.968). For women with adnexal tumors, indices with high accuracy are available that are applicable in clinical practice and comparable to an expert subjective sonographic assessment for discriminating benign from malignant masses.

Mutational analysis of BRCA1/2 in a group of 134 consecutive ovarian cancer patients. Novel and recurrent BRCA1/2 alterations detected by next generation sequencing.

The importance of proper mutational analysis of BRCA1/2 in individuals at risk for hereditary breast and ovarian cancer syndrome is widely accepted. Standard genetic screening includes targeted analysis of recurrent, population-specific mutations. The purpose of the study was to establish the frequency of germline BRCA1/2 mutations in a group of 134 unrelated patients with primary ovarian cancer. Next generation sequencing analysis revealed a presence of 20 (14.9%) mutations, where 65% (n = 13) were recurrent BRCA1 alterations included in the standard diagnostic panel in northern Poland. However, the remaining seven BRCA1/2 mutations (35%) would be missed by the standard approach and were detected in unique patients. A substantial proportion (n = 5/12; 41%) of mutation-positive individuals with complete family history reported no incidence of breast or ovarian cancer in their relatives. This observation, together with the raising perspectives for personalized therapy targeting BRCA1/2 signaling pathways indicates the necessity of comprehensive genetic screening in all ovarian cancer patients. However, due to the limited sensitivity of the standard genetic screening presented in this study (65%) an application of next generation sequencing in molecular diagnostics of BRCA1/2 genes should be considered.

Management of symptomatic ascites and post-operative lymphocysts with an easy-to-use, patient-controlled, vascular catheter.

OBJECTIVE: Malignant ascites (MA) can be managed with paracentesis, diuretics, shunt-systems, chemotherapy, and targeted therapies. Some treatments are ineffective; others are associated with complications, involve inpatient procedures, or are not cost-effective. Postoperative lymphocysts (LCs) are managed with inpatient drainage and sclerotherapy or surgery. We tested the use of a vascular catheter in the management of symptomatic MA and LC. METHODS: Fifty-five patients with primary or recurrent cancers with ascites or LCs were managed for symptom relief. A central venous 14-Ga 16-cm catheter (Arrow) was inserted into the abdominal cavity or LC, followed by drainage. RESULTS: The catheter was safely inserted with ultrasound guidance in 43 patients with MA (39 with ovarian cancer: 9 before primary cytoreduction, 30 with recurrence; 4 non-gynecological cancers), and 12 patients with LCs (10 retroperitoneal, 2 bilateral inguinal). All procedures were performed in the outpatient department under local anesthesia, without insertion-related complications. Within a mean of 30 days after catheter placement (range: 7-90 days), no grade 3 infection, peri-drain leakage, or self-removal was noted. In three patients with recurrent ovarian mucinous ascites and one patient with an inguinal LC, some drain obstruction was noted. In cases before primary cytoreduction for ovarian cancer, drainage enabled better nutritional and anesthiological outcomes. Patients with chronic ascites were able to self-monitor the amount of evacuated fluid. Twelve patients whose ascites were drained had chemotherapy at the time, and they reported better well-being, and we estimated better performance status. LC drainage followed by sclerotherapy enabled symptom control and LC radical treatment. CONCLUSION: The use of the vascular catheter is safe, easy, and cost-effective in the management of symptomatic MA and LC.

Creation of the Polish version and adaptation of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Endometrial Cancer Module (QLQ-EN24).

AIM OF THE STUDY: The purpose of this study was to create and introduce a Polish version of the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire for Endometrial Cancer (QLQ-EN24). MATERIAL AND METHODS: The translation procedure described by the EORTC was adopted; this comprised two independent forward translations of the original English questionnaire into Polish, two independent backward translations from Polish to English and pilot testing conducted on 12 patients with diagnosed endometrial cancer. They were asked whether there was any difficulty in answering, confusion while answering, or difficulty in understanding the questions, and if the patients themselves would have framed the questions in a different way. RESULTS: During the process of translation, discussions and text corrections were performed by medical experts and native English speakers. Some sentences or phrasing were adopted from other EORTC questionnaires for different diseases. After pilot testing, further text corrections were adopted according to patients' comments. These involved wording, sentence structure, and text editing (font size, bolding). CONCLUSIONS: The final version of the Polish EN24 questionnaire has been approved by the EORTC Translational Office. It is available on the EORTC web page now.

[Intestinal obstruction during pregnancy]. / Niedroznosc przewodu pokarmowego u kobiet ciezarnych.

This is a review of literature concerning intestinal obstruction in pregnant women. Approximately 50-90% and 30% of pregnant women, respectively suffer from nausea and vomiting, mostly during the first trimester. There is also increased risk of constipation. During the perioperative period, the administration of tocolytics should be considered only in women showing symptoms of a threatening premature delivery. Intensive hydration should be ordered to sustain uterine blood flow. The incidence of intestinal obstruction during pregnancy is estimated at 1:1500-1:66431 pregnancies and is diagnosed in II and III trimester in most cases. However, it can also occur in the I trimester (6%) or puerperium. Symptoms of intestinal obstruction in pregnancy include: abdominal pains (98%), vomiting (82%), constipation (30%). Abdominal tenderness on palpation is found in 71% and abnormal peristalsis in 55% of cases. The most common imaging examination in the diagnosis of intestinal obstruction is the abdominal X-ray. However ionizing radiation may have a harmful effect on the fetus, especially during the first trimester. X-ray is positive for intestinal obstruction in 82% of pregnant women. Ultrasonography and magnetic resonance imaging are considered safe and applicable during pregnancy. Intestinal obstruction in pregnant women is mostly caused by: adhesions (54.6%), intestinal torsion (25%), colorectal carcinoma (3.7%), hernia (1.4%), appendicitis (0.5%) and others (10%). Adhesive obstruction occurs more frequently in advanced pregnancy (6% - I trimester 28% - II trimester; 45% - III trimester 21% - puerperium). Treatment should begin with conservative procedures. Surgical treatment may be necessary in cases where the pain turns from recurrent into continuous, with tachycardia, pyrexia and a positive Blumberg sign. If symptoms of fetal anoxia are observed, a C-section should be carried out before surgical intervention. The extent of surgical intervention depends on the intraoperative evaluation. Intestinal torsion during pregnancy mostly occurs in the sigmoid colon and cecum. Small bowel torsion secondary to adhesions is diagnosed in 42% of pregnant women with intestinal obstruction. The risk of intestinal torsion is higher in the 16-20 and 32-36 weeks of pregnancy and during puerperium. Intestinal torsion results in vessel occlusion which induces more severe symptoms and makes urgent surgical intervention necessary. The overall prognosis is poor--during II and III trimester the fetal mortality rate reaches 36% and 64%, respectively while the risk of maternal death is 6%. Acute intestinal pseudoobstruction can be diagnosed during puerperium, especially following a C-section. Diagnosis is made on the basis of radiological confirmation of colon distension at the cecum as > 9cm, lack of air in the sigmoid colon and rectum, exclusion of mechanical obstruction. In most cases, the treatment is based on easing intestine gas evacuation and administering neostigmine. The authors point out the need for multi-specialty cooperation in the diagnostic-therapeutic process of pregnant women suspected with intestinal obstruction, since any delay in making a correct diagnosis increases the risk of severe complications, both for the woman and the fetus.

[Appendicitis and gall bladder diseases as acute abdominal conditions in pregnancy]. / Zapalenie wyrostka robaczkowego i choroby pecherzyka zólciowego jako stany ostre wymagajace pilnej interwencji chirurgicznej u kobiet w ciazy.

Appendicitis (APP) and gall bladder diseases (GBD) are the most frequent non-obstetric indications for urgent surgery among pregnant women. The aim was to present the diagnosis, treatment and potential complications of APP and symptomatic GBD. We searched the literature for APP and GBD during pregnancy and presented the results in the form of a review article. APP symptoms among pregnant women are comparable to these in the general population. Typical clinical symptoms are present in 50-75% of cases. Laboratory tests are useful for a differential diagnosis. The imaging of choice is an ultrasonography scan, but magnetic resonance is of the highest accuracy The final diagnosis is difficult. When the surgery is delayed, the risk of appendix perforation increases and thus complications are more frequent. GBD symptoms and signs are comparable to those in the general population. The best imaging is an ultrasonography scan, and laboratory tests are important in a jaundice differential diagnosis. In cases with symptomatic GBD, a delay in surgery is associated with an increased risk of complications (pancreatitis, abortion, intrauterine death). The treatment method of choice for APP and symptomatic GBD is surgery both laparotomy and laparoscopy (preferred), which are considered relatively safe, though laparoscopy compared to laparotomy for APP can be associated with a higher risk of abortion. Untreated or delayed APP and symptomatic GBD treatment during pregnancy increases the risk of complications, both for the woman and the fetus. Diagnosis is difficult and should be based on a multidisciplinary approach to the patient. Surgery by laparotomy or laparoscopy is relatively safe.

[Giant ovarian tumor--case report and proposal for clinical management]. / Olbrzymi guz jajnika--opis przypadku i propozycja postepowania klincznego.

A case report of a woman with 90 kg ovarian tumor is presented. Paracentesis and intravenous alimentation was performed before operation. During the surgery the ovarian tumor was excised and abdominal cavity packing, followed by slow pressure decreasing, was done. Intravenous together with oral alimentation was continued after the operation. The patient was discharged on the 10th postoperative day without any complications, in a good overall condition.

[The correlation between prognostic factors and outcome of second look laparotomy in ovarian cancer]. / Ocena zaleznosci pomiedzy wybranymi czynnikami prognostycznymi a wynikiem operacji sprawdzajacej typu "second look" u chorych na raka jajnika.

OBJECTIVES: The objective of this study was to verify the correlation between prognostic factors, positive or negative second look laparotomy (SLL) and 5-year survival in patients with ovarian cancer. MATERIAL: Between 1984 and 1993, 178 patients after primary surgery and first-line chemotherapy with complete clinical response underwent second look laparotomy. The correlation between clinical stage and grade of cancers, residual disease, age of patients in two group of patients: with positive and negative second look laparotomy were evaluated. RESULTS: 95 patients (53%) had positive SLL. The 5-years survival in this group was only 20%. Adverse prognostic factors were: advanced primary stage (IV-0% of 5-years survival), low grade of differentiation (9.1% of 5-years survival) and residual disease > 2cm (9.4% of 5-years survival). The 5-year survival in group with negative SLL was 78.3%. The analysed prognostic factors in this group were insignificant in predicting 5-year survival. CONCLUSIONS: This study confirms that the SLL can provide an important prognostic evaluation in patients without evidence of disease and allows surgical cytoreduction in group with positive SLL (more than 50% of patients). The analyzed prognostic factors in group with negative SLL were insignificant in predicting 5-year survival. The multicenter research for new prognostic factors in this group are required.

[New techniques with biodegradable Valtrac-Bar rings for intestinal anastomosis management of advanced cancer]. / Nowe techniki zespolen jelitowych za pomoca biofragmentowanych pierscieni dociskowych typu Valtrac-Bar w przebiegu leczenia zaawansowanego raka jajnika.

AIM: In the study we tried to demonstrate usefulness of the biofragmentable Valtrac-Bar rings in treatment of intestinal obstruction caused by advanced ovarian carcinoma. MATERIALS AND METHODS: Intestinal anastomosis with biofragmentable Valtrac-Bar rings were performed in 26 patients with advanced ovarian cancer with symptoms of intestinal obstruction. In nine patients manifestation of acute or subacute intestinal obstruction symptoms, cachexia and ascites necessitated the use of Valtrac rings during primary surgical operation. In the other 17 women we observed recidive of the disease causing obstruction mainly in the lower part of the digestive tract. Eight sigmoid, six sigmo-rectal and three ileo-ileal Valtrac-Bar rings anastomosis were done after secondary cytoreductive surgery. RESULTS: In 25 treated women we achieved improvement of their general condition, so we were able to continue treatment by chemio- or radiotherapy. Only in one treated patient further relaparotomy with colostomy was needed due to of anastomosis leak. CONCLUSIONS: We conclude that biofragmentable valtrac-Bar rings are very useful, safe and effective tools enabling fast intestinal anastomosis even in patients with inappropriate healing, for instance treated previously by chemio- et radiotherapy.